Patient Intake History Form
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1PATIENT INTAKE HISTORY
DATE: _________________
SS#_______________________________________
NAME:______________________________________________________________________
AGE:______________________________________
ADDRESS:__________________________________________________________________
DATE OF BIRTH:________________________
______________________________________________________________________________
INSURANCE:____________________________
HOME PHONE#____________________________________________________________
WORK PHONE#:_______________________
PARENT/GUARDIAN:______________________________________________________
CELL PHONE#:_________________________
EMERGENCY CONTACT:___________________________________________________
ALT PHONE#:__________________________
PATIENT MEDICAL HISTORY:
(eg. Diabetes, asthma, emphysema, high blood pressure, heart disease, tuberculosis, cancer, thyroid, etc.,
include hospital stays):
______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
PAST SURGICAL HISTORY:
(include all, no matter how long ago. Eg. appendectomy, hysterectomy, gall bladder, tonsils, cesarean section)
______________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________
ALLERGIES: (food, drug, insect, and others):
OTHER PHYSICIANS YOU ARE SEEING:
_____________________________________________________________
_____________________________________________________________________
_____________________________________________________________
_____________________________________________________________________
CURRENT MEDICATIONS: (include dosage and frequency):
________________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________
FAMILY HISTORY
SOCIAL HISTORY
Age
Health/Major Illness
Marital Status: _______________________________
Mother: ____________ ________________________________________________
Occupation: __________________________________
Father: ____________ ________________________________________________
Alcohol:________________________________________
Siblings: ___________ ________________________________________________
Tobacco: ______________________________________
____________ ________________________________________________
Coffee/Caffeine: ______________________________
____________ _________________________________________________
Exercise: ______________________________________
Children: __________ _________________________________________________
Special Diet: __________________________________
____________ _________________________________________________
Travel Outside US: ___________________________
I authorize Dale L. Deahn, MD to release information/test results to: __________________________________________________,
Unless otherwise notified.
Relationship to patient:___________________________________________________
SIGNATURE: _________________________________________________________ DATE:_________________________ UPDATED:_______________
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Parent category: Business